Corrective Action Plans

Finding 5697 (2022-002)

Significant Deficiency 2022

TN

Reporting Internal Control / Segregation of Duties

Action Taken: Director of Federal Programs, CEO and Director of Operations and Finance have all been made aware of this finding and will oversee the process to ensure the books are closed timely.

View Audit 7695

Finding 5609 (2022-004)

None 2022

City of Muldraugh

KY

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN December 13, 2023 Department of Local Government The City of Muldraugh respectfully submits the following corrective action plan for the year ended June 30, 2022. SK LEE CPAS, P.S.C P.O. Box 958 Berea, KY 40403 The findings from the June 30, 2022 schedule of findings and q...

CORRECTIVE ACTION PLAN December 13, 2023 Department of Local Government The City of Muldraugh respectfully submits the following corrective action plan for the year ended June 30, 2022. SK LEE CPAS, P.S.C P.O. Box 958 Berea, KY 40403 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2022 - 001 Financial Statement Preparation Recommendation: Management should continue to engage the audit firm to prepare a draft of the financial statements including the notes to the financial statements, or hire an accountant to perform these services. Action taken: Management concurs with the finding, however, due to limited economic resources cannot hire an accountant at this time and will continue to engage the audit firm to draft the financial statements including the notes to the financial statements. 2022- 002 Segregation of Duties Recommendation: The lack of segregation of duties is a common deficiency in cities the size of Muldraugh Action taken: Management concurs with the finding, however, due to limited economic resources cannot hire staff to properly segregate the duties required of the City. NON - COMPLIANCE 2022 - 003 Late Audit Report Recommendation: The City should engage audits with sufficient time to complete the engagement by the required date. Action taken: Management concurs with the finding and will have the audit completed by the required date. 2022 - 004 Late Submission of Data Collection Form Recommendation: The City should complete their DCF by the required date. Action taken: Management concurs with the finding and will have the data collection form completed by the required date. If the Department of Local Government has questions regarding this plan, please call Anthony Lee at (502) 942-2824. Sincerely yours, _____________________________________________________________ Anthony Lee, Mayor of Muldraugh, Kentucky

View Audit 7454

Finding 5582 (2022-003)

Significant Deficiency 2022

Rainbow Health

MN

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.328 § 200.512

Views of Responsible Officials and Planned Corrective Actions: We agree with this finding and have implemented the following internal control policies and procedures concerning the timeliness of financial activities: Rainbow Health Minnesota is reimplementing monthly board meetings that will includ...

Views of Responsible Officials and Planned Corrective Actions: We agree with this finding and have implemented the following internal control policies and procedures concerning the timeliness of financial activities: Rainbow Health Minnesota is reimplementing monthly board meetings that will include a financial review of income and expense reports and balance sheets. The lateness for the 2022 audit was partially due to staff turnover of the CFO and the subsequent review by the new Finance Director. Responsibility for administering this process resides with the Finance Director

View Audit 7441

Finding 5505 (2022-006)

Significant Deficiency 2022

Santa Fe Community Housing Trust

NM

Questioned Costs Reporting Significant Deficiency § 200.512

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. Thi...

The contractors hired to do the accounting and payroll functions are no longer under contract with the Housing Trust. All financial functions are now being taken care of in-house. The financials are already in the process of being adjusted and all numbers being accounted for with documentation. This will continue through 2023 and in 2024, the chart of accounts will be changed to reflect the current practices for a nonprofit organization. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department has started. Staff changes will also need the Business Operations manager to provide a thorough monthly review. The current administrative assistant will take on the role of accounting technician to handle the day-to-day QuickBooks-related processes. Work has already started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designated Employee Responsible for Corrective Action: Business Operations Manager

View Audit 7270

Finding 5501 (2022-002)

Material Weakness 2022

Santa Fe Community Housing Trust

NM

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.430

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to e...

Response. Agreed. Where feasible, the Housing Trust will aim to improve management of all federal grants. A process of documentation verification prior to any requests made for financial draws will include employee, supervisor, business operations manager, and executive director level approvals to ensure compliance and availability of funds. A monthly federal request for reimbursements with all grantee information will be used and reconciled monthly with QuickBooks. This report will mirror the SEFA form so auditors will receive the information in a timely manner. For any quarterly reports, the three months of reporting will again be reconciled prior to submission. All new processes and compliance will be updated in the policies and procedure manual. As the Executive Director prepares the 2024 budget, a reorganization of the business operations department will be sought. A new position to prepare and work on all federal grant tasks will be hired and report to the Business Operations Manager. In the meantime, the Business Operations Manager has started to develop checks and balances. Corrective Action Plan Timeline: Immediately Designation Of Employee Position Responsible For Meeting Deadline: Business Operations Manager

View Audit 7270 Questioned Costs: $1

Finding 4958 (2022-007)

Significant Deficiency 2022

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School C...

Condition: Suspension and debarment compliance is not verified for all covered transactions. Corrective Action Planned: The School Comptroller will ensure that all vendors are checked using SAM for suspension and debarment for all covered transactions in compliance with federal laws. The School Comptroller will print out the support and include with each grant. Anticipated Completion Date: Completed Contact: Robert Dickinson, City Auditor

View Audit 7220

Finding 4454 (2022-002)

Material Weakness 2022

Virginia Association of Recovery Residences INC

VA

Internal Control / Segregation of Duties

VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship...

VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship with the Virginia Department of Behavioral Health Development Services and our recovery community centers provide an external layer of control that when tied into our software system known as REC-CAP will alert management when an error occurs. We expect that we will enhance the development of our systems to capture and provide for the seamless integration of this finding by January 31, 2024. This action is in accordance with the requirements of Uniform Guidance 2 CFR §200.511(c).

View Audit 6879

Finding 4444 (2022-002)

Material Weakness 2022

West Monona Community School District

IA

Internal Control / Segregation of Duties Reporting

We continue to look for ways to improve our internal controls.

View Audit 6871

Finding 4420 (2022-002)

Material Weakness 2022

Community Counseling Solutions

OR

Reporting Internal Control / Segregation of Duties Questioned Costs

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

View Audit 6868

Finding 4413 (2022-001)

Material Weakness 2022

Community Counseling Solutions

OR

Reporting Internal Control / Segregation of Duties

Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.

View Audit 6868

Finding 4407 (2022-002)

Material Weakness 2022

Central Decatur Community School District

IA

Internal Control / Segregation of Duties

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees

View Audit 6862

Finding 4385 (2022-002)

Material Weakness 2022

Schc Companies, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Eligibility Reporting

2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...

2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023

View Audit 6819

Finding 4382 (2022-001)

Material Weakness 2022

Schc Companies, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organiz...

2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organizations’ signature approval on the documentation received and the fee calculated and provided to the applicant. All applications should contain support for the individual’s income level or documentation of no income, and the determination of the resulting fee. Action Taken: This finding was repeated in 2022. Since this was a repeat finding, an internal audit was performed on all 2023 approved sliding fee applications to ensure compliance with our policy. Any corrective actions to the 2023 application were address and the facility’s sliding fee scale was modified to reflect proper authorization and proper segregation of duties going forward. Going forward, all sliding fee scale applications are now reviewed and authorized by the Manager of Revenue Cycle. Future auditing procedures have been put in place to review applications and adjusted, if needed, in a timely manner between now and the end of the year. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023

View Audit 6819

Finding 4162 (2022-004)

Significant Deficiency 2022

Township of Bloomfield

NJ

Questioned Costs Reporting Internal Control / Segregation of Duties

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...

Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing

View Audit 6483

Finding 4161 (2022-003)

Significant Deficiency 2022

Township of Bloomfield

NJ

Questioned Costs Reporting Internal Control / Segregation of Duties

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...

Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing

View Audit 6483

Finding 4160 (2022-002)

Significant Deficiency 2022

Township of Bloomfield

NJ

Questioned Costs Allowable Costs / Cost Principles Cash Management

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...

Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing

View Audit 6483

Finding 4121 (2022-003)

None 2022

The Bridge Over Troubled Waters, Inc.

TX

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.512

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to d...

Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to due dates in case there is a computer issue. If a report is late, request an exception/extension in writing to file with report. Contact: Evelyn Vargas, Grants Compliance Manager Expected Completion Date: 11/30/2023 If you have any questions, please contact Evelyn Vargas at 713-472-0753 or by email at evargas@tbotw.org.

View Audit 6440

Finding 4038 (2022-002)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 4037 (2022-001)

Significant Deficiency 2022

Granville Health System

NC

Questioned Costs Cash Management Significant Deficiency

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...

Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023

View Audit 6359 Questioned Costs: $1

Finding 3992 (2022-004)

Significant Deficiency 2022

City of Depere

WI

Questioned Costs Reporting Significant Deficiency

Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.

View Audit 6296

Finding 3979 (2022-001)

Significant Deficiency 2022

Hodgeman County, Kansas

KS

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the U...

U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

View Audit 6270

Finding 3959 (2022-001)

Material Weakness 2022

Municipality of Delmont

SD

Internal Control / Segregation of Duties Material Weakness

The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of the size of the City of Delmont, the City cannot support the internal controls needed to properly segregate duties. The City Council Members and Finance Office employees are aware of the ...

The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of the size of the City of Delmont, the City cannot support the internal controls needed to properly segregate duties. The City Council Members and Finance Office employees are aware of the problem. We will be working on some different policies and controls that will help minimize the future risk. This will be an ongoing process that will include input from the State Auditor's Office, talking to other municipalities and utilizing the council members in some of the financial controls.

View Audit 6229

Finding 3952 (2022-002)

Significant Deficiency 2022

Iowa Northland Regional Housing Authority

IA

Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.

View Audit 6226

Finding 3951 (2022-001)

Significant Deficiency 2022

Iowa Northland Regional Housing Authority

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.

View Audit 6226

Finding 3876 (2022-006)

Significant Deficiency 2022

Camcare Health Corporation

NJ

HUD Housing Programs Questioned Costs Special Tests & Provisions

Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsib...

Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO

View Audit 6120

Corrective Action Plans

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